Reading sustainability where the health system is the constraint
Where a health system is short of power, water, money and literacy, as in Africa, sustainability is a matter of access and upkeep as well as of carbon.
What sustainability means in the African context
In the view of a South African public and environmental health academic, given in 2024, sustainability in the African context is about much more than green carbon footprints and the race to net zero inside the health system: it is also about addressing people's needs, improving access to care for rural communities, and ensuring that whatever is provided can be maintained and supported over time. On that view, the healthcare services delivered in Africa, and the facilities that deliver them, have to be sustainable.
Health targets for Africa run to two horizons: Sustainable Development Goal 3 to 2030, and the African Union's Agenda 2063, whose aspiration 1.3 covers health and welfare, to 2063, with national development plans of individual countries such as South Africa beside them. The same academic holds that work towards 2030 should keep in view the aspiration that by 2063 there is an aware citizenry that is healthy and can work and be productive.
Burden of disease
As of 2024, Africa had the highest burden of disease in the world and, with 15% of the world's population, half of global deaths from communicable disease. Malaria and tuberculosis were also problems across the continent. Sub-Saharan Africa had the highest prevalence of HIV/AIDS, and non-communicable diseases such as cancer, cardiovascular disease, diabetes and chronic lower respiratory disease were becoming the main cause of mortality there, accounting for over a third of the region's deaths.
Health infrastructure
Africa's health system is beset by ageing and oversubscribed infrastructure, and the combination of underinvestment, a high and increasing burden of disease and high population growth leaves the continent short of health infrastructure. That infrastructure is unevenly distributed across the continent, because African countries lack resources for their health systems. Hospitals lack the equipment and technology to diagnose and treat, and coverage is often of poor quality and has major gaps in rural areas, which make up the greater part of most African countries and whose residents need good-quality care at all times.
In sub-Saharan Africa, only half of primary healthcare facilities had access to clean water and adequate sanitation and only a third to reliable electricity, and the unreliable supply of energy also impairs the provision of potable water and sanitation. At least 25,000 healthcare facilities there had no electricity at all and only half of hospitals had a reliable supply, and an estimated 30 to 40% of vaccines went bad for want of it, becoming waste that then had to be disposed of. Waste disposal is itself a challenge on the continent, especially for healthcare risk waste, which has to be disposed of properly so that it causes no needlestick injuries or transmission of infection.
Health spending
Health expenditure in sub-Saharan African countries averaged 5.1% of gross domestic product in 2018, against 6.7% in East Asia and the Pacific. Government health expenditure was 1.9% of gross domestic product in sub-Saharan Africa, far below the target suggested by the United Nations Economic Commission for Africa. Only around 6% of total public health spending in Africa went to developing health infrastructure, and only 52% of African citizens had access to the healthcare they needed. The 4.5 billion that African governments invested in public health capital expenditure was far below the estimated 26 billion a year of investment in new healthcare infrastructure.
The same academic holds that without spending on new or refurbished health infrastructure, Africa is unlikely to reach either its targets for reducing carbon emissions or full health coverage. On that view, budget has to be set aside for the transition towards cleaner technologies and environmental sustainability in the health sector, and spending too little is a barrier that slows the provision of the health services needed.
Energy supply and solar power
As of 2024 the electrical grid in many African countries was unreliable, and in most of them it relied heavily on fossil fuels, mainly coal, with diesel generators as backup. Because budgets for moving to cleaner energy sources are limited, a diesel generator is the quick solution when the power fails, but it produces a lot of carbon emissions. Many African countries had slowly been moving to cleaner energy, mainly solar, to give health services a reliable supply.
Solar lighting and off-grid systems let some 600 clinics across southern Africa treat patients outside daylight hours. In Nigeria, hundreds of hospitals ran on solar hybrid systems, with a further phase aimed at 400 trauma centres. Other examples were a hybrid energy grid for university and teaching hospitals and, in Nigeria, containerised solar hybrid systems that powered ventilators and the refrigeration for storing vaccines and medicines. Such systems help reduce the waste of vaccines and medicines that spoil when there is no refrigeration or the power supply is interrupted. They were proving very important to the health system on the continent, and in the same academic's reading they show that governments have realised the need for an uninterrupted supply of electricity. As of 2024, in the province that is South Africa's economic hub, solar systems were planned for 27 healthcare facilities and only half of the installations had been completed, mainly because of budget restrictions. For the same academic, the shortfall shows that governments must invest, and without that investment countries are likely to lag behind and to incur more waste and a greater burden of disease.
The same academic holds that governments must be aware that, although solar is quick to install and can be used at once, its panels and batteries age, and a continent that does not make them locally has to consider, on the 2063 horizon, what happens to them as waste. As of 2024 South Africa had extended producer responsibility regulations that required a producer to take a product back once its lifespan was over, but such regulations were not applied across the continent. African countries share similar problems but differ in financial capacity and in population, so what is done depends on the country. On that view, a government adopting a technology has to ask whether it has the capacity to deal with the waste the technology will become and with the energy it will consume.
Water
Shortfalls in providing water and wastewater services add to water contamination, environmental pollution and the emergence of diseases that were not there before. The same academic thinks environmental awareness and education can play a major role in addressing them.
In 2024 South Africa's supply of water from a dam in a neighbouring country, which was being expanded, was cut for nine months for maintenance, and awareness campaigns asked people to use water sparingly. Municipalities around the country were having problems as water levels fell, and overflowing sewage was causing much pollution. In another interruption that year, the cause was given as an electricity problem in the system of the agency that supplies the water. Communities draw on groundwater and surface water, they use water whenever they see it there, and there is no communication.
The same academic holds that, to secure clean water, government must put policies in place and use its regulatory authority to charge polluters. On that view, leaking infrastructure has to be fixed, since South Africa loses much clean water to leaks, and people have to be educated. Water can be purified to make it clean, but ideally it would not be polluted in the first place.
After floods in one South African province destroyed the infrastructure that supplied water, the academic's team developed an assessment tool that sets a hospital's water reserves against its number of admitted patients. In that work, each hospital or health centre must have its own water demand management system.
Literacy
As reported in 2024, 65.9% of people in Africa aged 15 and over could read and write, and the adult literacy rate varied by gender, with 59.4% of women literate. The same academic holds that people need to read and write so that they can understand the information given to them, make sense of it and change their behaviour, and that low literacy has to be addressed. On that view, education should help people understand how climate change and health are related and how their behaviour affects their own health and that of others. Education and awareness raising are, for the same academic, a tool for ensuring sustainable healthcare services.